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Home My WebLink About0800 BEARSE'S WAY (18) A& TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcels Application # CWI -6 � Health Division Date Issued �� Z Conservation Division (�� Application Fee Jed Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village . O 11A 4)10'4 Owner 0A`I_1� I-) X1 ;:� Address P.06 5-1 &fit 5/®yO AA. 44 `q Telephone Permit Request 464taex,, _'' z LwnlLl . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /500- — Construction Type [e1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout der S Zwln Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION ,(BUILDER OR HOMEOWNER) Name Telephone Number Address License # L- 4f;_A_ VT:)k!)10A,1 Y14A Home Improvement Contractor# �16- e6 L2J Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /(P ` �" FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE ' OWNER :. DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 4 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizaliottlIndividual):� ��Q�}U �-D/F/A T)i lj�Qr`- l l{� Address: PY I Boy Ajgnl q City/State/Zip; Sarduil Phone Are you an employer?Check the appropriate box: Type of project(required): 1.CQ I am a employer with 1O 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance. 9, ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation.insurance for my employees. Below is the policy and job site information. Insurance Company Name: z d , Policy#or Self-ins.Lic.#: 47 1 a A P !.00 Expiration Date: Job Site Address• mow o� City/State/Zip- Attach a copy of the workers' compensation pollc declaration page(showing the policy nuAber and expiration date). Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the.DIA for insurance coverage verification. I do hereby cer if fill a thepains and penalties ofperjury that the information provided above is true and correct. signafire: Date: Phone#: - Official use only.. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: RightF'ax 141-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server ISSUE DATE 12122/2011 THIS CERTIFICATE IB ISSUED AS A MATTER OF INFOR1,1AT10N ONLY AND CONFERS NO RIGHTS UPON TILE CERTIFICA HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW,TIRE CERTMCATE OF UNSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 19SUING 1NBURER(SN KUTHORNU REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;H the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed,if SUBROG TION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate It es not confer rights to the certNlcate holder In Hsu of such endorsements. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: AX 52 WEST MAIN STREET acNNo,Eat): HYANNIS,MA 02601 64AL ADDRESS: PRODUCER CUSTOMER ID T. INSURED INS S AFFORDING COVERAOE NAIC# BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSUREg B P O BOX 480 WSURERC SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 13 TO CERTIFY THAT TEIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSU®TO THE INSURED NAMED ABOVE F R THE POLICY PERIOD INDICATED. N0TWr=TANDB70 ANY REQUIRPMBNT,TERM OR CONDTRON OF ANY CONTRACT OR OrTHM DOCUMENT WIT ZI RESPECT TO CH TEIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED II EREIN 18 SUBJECT TO ALL THE TERMS, CLU31ONS AND CONDITIONS OF SUCH POLICES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID Cf.AIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY E LEWTS LTR INSR WVD D/YYYYI GENERAL LIABILITY , EACAOCCURRENCE 3 DAMAOETORENTED s 000hR4ERCW,OLNERALIIABILMY PRD4M(Eech occurrence 1 mIe Q CLADAS MADE 0 OCCUR. MID.WENSE(My S person 0 PERSONALaADV S INJURY I OENERALAOOREOATE S 0 GEN'L AGOREOATE L ,11T APRI S PER PRODUCTS-COIN/OP S 0 POLICY 0 PROJECT 0 LOC AOO AVTOMORILEI.,IARD.ITY CO`1aWDSINOLE S LRIW ch secldenl 0 ANY AUTO BODILYINMY S M Perr BODIYRUURY f 0 ALL owttSD AlrroS er Acciderd) O BCHmUI.ED AUTOS PROPERTY DAMAGE S (Per mdent 0 HIRED AUTOS I 0 N0N•OWNFD AUTOS S 0 0 UMBRELLALIAB 000CUR 1 EACH OCCURR?YCE S 0 EXCESS LIAR 0 CLAIMS-MADE AOGREGATE S 0 DEDUCT IE S 0 REM47ONS S WORKERS'COMPENSATION ! µ`C A AND EMPLOYERS LIABU]TY N/A STATUTORY YIN I LR.ff[S ANY PROPRMTORIPARTNP.R/ - LEACH ACCIDENT SSOO,000 EXCLUTIDE OFFICBR/bg:+�ER N NIA 6ZZU84102P700 01/01/12 01/01/13 I (MArroATORYINNM EL�y�="�H s500,000 ' i rr yes,describe under DESCRIPTION OF L DMASS-POLICY OPERATTONSbelov ,, SS00,000 UESCRIPriONOPOPERA77olgafLOCAttoli$N RICLES(A@aeh ACORDIOI,Addilianel Remvks SeheMe,irrrore.pueurequiraQ THF.O$TIREDB MA'NORKERS COMPENSATION POLICY AND ITS 12MM OTHER STATES WSURANCE ENDOREEMEM AUMORIZES THE PAYMEN*VOF BENEFITS FOR CLAMS MADE BY THi.INSURED' EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS(IrNN TO PAY CLAIMS FOR BENEFITS IN ANY SIATE OrrrMR THAN MA U T HE INSURED HIRES,OR HAS IIIRED,EMPLOYEES OUTSIDE MA THIS POLICY DOES NOT PROVIDE COVERAOE^OR ANY MATE O1HEP THAN MA i THIS REPLACES ANY PR10R CERT.'RRCATE IRSDM 70771E CERTIFICATS HOLDER AFFECTING WOR=C MP COVERkOE i.,,l n r e . t^1 S y 1 CtAIA uE. tilt): s,k a Y� we ro, ;; SHOULD ANY OF THE ABOVE DEDC ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR VISIONS. ...-. AUIHORITJD RFPRESMOATIVE 8rltiuv Mas(.eaw 'AC,C012`QI25 0D91,4..?i, �, 'Y„:�..,+�r,: . . � �' .'^.��'c£r '�;�` '��s�3Y�c�"�+!zt4,�` ,598&JF4b�`L''0 fSI�c't'�{SkY.>918•Y., 't'�eea1't61:e�: i L Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supers kor License:CS-071402 JOSIEIUA L C01fiN 1082 OLD SI A CENTERVIELE ! J.•�: � ��'' Expiration Commissioner 12131/2013 3 &2e �poa�vr�waacaeal� ffice of Consumer Affairs&Business Reg ulati me4ea ME IMPROVEMENT CONT License or registration valid'for individul use only ,. RACTOR before the expiration date. If found return to: egistration 108642 ® Office of Consumer Affairs and Business Regulation Expiration g/20/2014;r Type' 10 Park Plaza-Suite 5170 BENABBy INC/DISASTER SuPPlement(,:ard SPECIALIST Boston,MA 02116 JOSHUA COHEN Box 480 5-1 Sandwich, MA 02563 ".�..� Undersecretary Not valid without signature THE ram, Town of Barnstable ° Regulatory Services • BMMSrABLE. 9 Mass �, Thomas F.Geiler,Director �A i63q. ♦0 rFvroo'�° Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, f/ ��/'U f��v�,� s�f ,as Owner of the subject property hereby authorize rc 'c--d e- to act on my behalf, in all matters relative to work authorized by this building permit. (Address of J b) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Gad S'atu.re o wner ature of Applicant Print Name Print Name Date . Q:FORM&OWNERPERMISSIONPOOLS 6/2012